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448

C: Formal Written Request for Financial Records -- Form DOJ-463

RFPA

Form DOJ-463 -- Formal Written Request for Financial Records

UNITED STATES DEPARTMENT OF JUSTICE

Washington, D.C. 20530

FORMAL WRITTEN REQUEST FOR FINANCIAL RECORDS

TO: _________________________________________________

_________________________________________________

(Name and Address of Financial Institution)

FROM: _________________________________________________

(Name of Government Agency)

In connection with a legitimate law enforcement inquiry, you are requested, pursuant to the Right to Financial Privacy Act of 1978, 12 U.S.C. Secs. 34O1-3422, and 28 C.F.R., Part 47, to assemble and __________________________ the following financial (reproduce/make available)

records pertaining to _________________________________________ :

(Name of Customer or Customers)

_______________________________________________________________

_______________________________________________________________

Upon your receipt of a Certificate of Compliance with the Right To Financial Privacy Act of 1978, you will be relieved of any possible liability to the customer in connection with the disclosure of these financial records.

____________ _____ , 19 ___ ______________________________

(Date) (Name and Title of Official)

___________________________ ______________________________

(Address) (Government Agency)

___________________________

(Phone)

Remarks:

Sec. 1108 of the Right To Financial

FORM DOJ-463

Privacy Act, 12 U.S.C. Sec. 3408; 28 C.F.R., Part 47